SLEEP STRATEGIES Treating childhood OSA

How is obstructive sleep apnea diagnosed in children?

Obstructive sleep apnea is diagnosed by overnight sleep study or polysomnography. Criteria for diagnosis of OSA in children can vary in the literature, but criteria used clinically are often similar to what was used in the CHAT trial: an obstructive AHI greater than 2 per hour or an obstructive apnea index (OAI) of greater than one per hour. Alternatives to an overnight sleep study have not yet been found for children. In adults, overnight oximetry, if normal, can be valuable in ruling out obstructive sleep apnea. In children, almost 50% of those screened with a normal oximetry went on to have sleep apnea during an overnight sleep study, making this an ineffective screening tool to rule out sleep apnea for most children (Brouillette et al. Pediatrics. 2000;105[2]:405). Home sleep testing has yet to be shown to be a reliable option in children but may be in the future (Tan et al. Chest;2015:148[6]:1382). Clinical history taking can be more challenging as well, as children do not typically have bed partners, and OSA is often clustered in the early morning hours in association with rapid eye movement sleep (REM), making parental observation less likely. These factors make overnight sleep studies the gold standard for diagnosis.

However, overnight sleep studies are costly, time consuming, and can be technically challenging in children depending on age and development. In certain areas, access to pediatric sleep centers can be limited. Overnight sleep studies can also be an additional economic burden to parents who are required to spend the night with their child, perhaps missing work and needing child care for other children in the family. All of this adds to the importance of identifying children who truly need to undergo a sleep study.

Can we change guidelines? Not yet.

We are not at a point where we can yet rewrite guidelines. The American Academy of Pediatrics (AAP) and the American Academy of Sleep Medicine (AASM) recommend a sleep study prior to proceeding to adenotonsillectomy in children. A repeat sleep study is recommended in children with moderate to severe OSA after adenotonsillectomy and when symptoms remain. Are there any other tools that can be used? New research may give suggestion as to which children can avoid repeating the costly and time-consuming test. In areas where sleep studies have limited availability, avoiding unnecessary testing is important.

Bottom line: More questions remain

The diagnosis and treatment of childhood OSA continue to challenge practitioners. While adenotonsillectomy is still the common treatment for OSA, it is reasonable to consider watchful waiting in some circumstances, particularly in children with mild disease. More questions still remain, however, in regards to the follow-up of these children. Practitioners still struggle with the definition of mild OSA in children (Is this an AHI less than 3, or is this an AHI less than 5? How do symptoms impact diagnosis and treatment?). Studies such as the CHAT trial are important first steps in helping to sort out the behavior of OSA in children long term. What happens to children farther out than 7 months? Additional research should help clarify these issues.

Dr. Baughn is a Consultant, Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota.